Provider Demographics
NPI:1043593809
Name:BRADSHAW, BERTINA
Entity Type:Individual
Prefix:
First Name:BERTINA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 ST. JOSEPH'S BLVD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:571 ST. JOSEPH'S BLVD.
Practice Address - Street 2:SUITE 102
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3230
Practice Address - Country:US
Practice Address - Phone:607-737-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161039939261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1023054376Medicaid